The Problem With Organized Psychiatry

Well, it happened again. I attended yet another professional conference this weekend (specifically, the annual meeting of my regional psychiatric society), and—along with all the talks, exhibits, and networking opportunities—came the call I’ve heard over and over again in venues like this one: We must get psychiatrists involved in organized medicine. We must stand up for what’s important to our profession and make our voices heard!!

Is this just a way for the organization to make money? One would be forgiven for drawing this conclusion. Annual dues are not trivial: membership in the society costs up to $290 per person, and also requires APA membership, which ranges from $205 to $565 per year. But setting the money aside, the society firmly believes that we must protect ourselves and our profession. Furthermore, the best way to do so is to recruit as many members as possible, and encourage members to stand up for our interests.

This raises one important question: what exactly are we standing up for? I think most psychiatrists would agree that we’d like to keep our jobs, and we’d like to get paid well, too. (Oh, and benefits would be nice.) But that’s about all the common ground that comes to mind. The fact that we work in so many different settings makes it impossible for us to speak as a single voice or even (gasp!) to unionize.

Consider the following: the conference featured a panel discussion by five early-career psychiatrists: an academic psychiatrist; a county mental health psychiatrist; a jail psychiatrist; an HMO psychiatrist; and a cash-only private-practice psychiatrist. What might all of those psychiatrists have in common? As it turns out, not much. The HMO psychiatrist has a 9-to-5 job, a stable income, and extraordinary benefits, but a restricted range of services, a very limited medication formulary and not much flexibility in what she can provide. The private-practice guy, on the other hand, can do (and charge) essentially whatever he wants (a lot, as it turns out); but he also has to pay his own overhead. The county psychiatrist wants his patients to have access to additional services (therapy, case management, housing, vocational training, etc) that might be irrelevant—or wasteful—in other settings. The academic psychiatrist is concerned about his ability to obtain research funding, to keep his inpatient unit afloat, and to satisfy his department chair. The jail psychiatrist wants access to substance abuse treatment and other vital services, and to help inmates make the transition back into their community safely.

Even within a given practice setting, different psychiatrists might disagree on what they want: Some might want to see more patients, while delegating services like psychotherapy and case management to other providers. On the other hand, some might want to spend more time with fewer patients and to be paid to provide these services themselves. Some might want a more generous medication formulary, while others might argue that the benefits of medication are too exaggerated and want patients to have access to other types of treatment. Finally, some might lobby for greater access to pharmaceutical companies and the benefits they provide (samples, coupons, lectures, meals, etc), while others might argue that pharmaceutical promotion has corrupted our field.

For most of the history of modern medicine, doctors have had a hard time “organizing” because there has been no entity worth organizing against. Today, we have some definite targets: the Affordable Care Act, big insurance companies, hospital employers, pharmacy benefits managers, state and local governments, malpractice attorneys, etc. But not all doctors see those threats equally. (Many, in fact, welcome the Affordable Care Act with open arms.) So even though there are, for instance, several unanswered questions as to how the ACA (aka “Obamacare”) might change the health-care-delivery landscape, the ramifications are, in the eyes of most doctors, too far-removed from the day-to-day aspects of patient care for any of us to worry about. Just like everything else in the above list, we shrug them off as nuisances—the costs of doing business—and try to devote attention to our patients instead of agitating for change.

In psychiatry, the conflicts are particularly wide-ranging, and the stakes more poorly defined than elsewhere in medicine, making the targets of our discontent less clear. One of the panelists put it best when she said: “there’s a lot of white noise in psychiatry.” In other words, we really can’t figure out where we’re headed—or even where we want to head. At one extreme, for instance, are those psychiatrists who argue (sometimes convincingly) that all psychiatry is a farce, that diagnoses are socially constructed entities with no external validity, and that “treatment” produces more harm than good. At the other extreme are the DSM promoters and their ilk, arguing for greater access to effective treatment, the medicalization of human behavior, and the early recognition and treatment of mental illness—sometimes even before it develops.

Until we psychiatrists determine what we want the future of psychiatric care to look like, it will be difficult for us to jump on any common bandwagon. In the meantime, the future of our field will be determined by those who do have a well-formed agenda and who can rally around a common goal. At present, that includes the APA, insurance companies, Big Pharma, and government. As for the rest of us, we’ll just pick up whatever scraps are left over, and “organize” after we’ve finished our charts, returned our calls, completed the prior authorizations, filed the disability paperwork, paid our bills, and said good-night to our kids.

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51 Responses to The Problem With Organized Psychiatry

Why doesn’t the profession start by being honest about its medications, which have both extraordinary dangers and can produce profound miracles? There is every reason to take a dangerous drug, at least for awhile, if you are losing everything, possibly including your life.
I teach large calculus classes. At some point I will make an informed consent speech and tell my students that the books I use are thick so that publishers can charge more, and yet, if you pay attention to the essence of what they present you will learn a lot. Big Pharma, big publishing, not much difference, in fact mathematicians are organizing a boycott against some big publishing.
It seems that the members of the psychiatry community have as much in common as the members of the law enforcement community as the members of the college/university community. When done right these professions make a hell of a positive difference, when done wrong……….

Honesty of what they know and what they don’t and some humility would be a great or start. Professional standing of psychiatrists is ultimately based on the quality and robustness of care patients receive. Staying afloat for the sake of it by trying to increase membership for their dues does not serve the profession, professionals, or patients, just the organization itself. It does not make psychiatry any more trustworthy, nor their theories, treatments, or outcomes any better. Surely members see that as silly? If not, psychiatrists aren’t showing much perceptive abilities or reasoning skills which does not bode well for engendering a trust based on anything of substance or for what psychiatrists do for people to earn their pay.

People/government already pay a lot for poor quality care. What is changing with the new health care legislation is that they will pay less for poor quality care, but still a lot. Incomes of psychiatrists are still very high. If psychiatrists want to use medical degrees for higher incomes, they should go and try to get a much more competitive residency in another specialty, or work to improve care (people would be willing to pay more if care can be shown to be good.) My understanding is that psychiatry residencies are comparatively pretty easy to get into given the “shortage” of psychiatrists, the dubiousness through which most medical students view in the field, and lower pay compared to other specialties.

In terms of disagreement in psychiatry, it seems that disagreements are primarily ideological. I see this as a failure to commit to providing care based on evidence of effect and worthwhile-ness to the patient (potential value of treatment divided by time, cost/burden, and risks of treatment). I am more understanding of practical disagreements regarding how psychiatry interfaces with the greater health care delivery system, but even those debates could/should be informed by quality research. Advocating and pursuing what works for people seeking support could unify psychiatry (research questions and research and produce meaningful results that inform practice), as opposed to taking ideological positions and trying to maintain professional standing and turf.

“Professional standing of psychiatrists is ultimately based on the quality and robustness of work” (thanks Nathan). End of story! Work in the private sector sometime. See what a nightmare it is to find a central consensus in getting those with a high regard for their important work. This makes me more nuts than I already am. If you do not stay at the top of your field, someone, better and younger, will be happy to kick you off.

When I say pool together, I mean it as a field…not dues…unions…commitees…ridiculous infighting. Stand up for those you heal and you will find that is what is expected. You bet, there are a number of variated ways and compensation in your esteemed field. But honestly, if you do not think your work is up to standard, step down and be quiet, because if you were in the real world, this would be so be expected and many ways of being dismissed. Mediocrity does not behoove most I have met. It has sadly often been the case and it becomes more difficult to be a financial and personal advocate for mental health. There is brilliant work and great advances in Psychiatry and it is one of the very few things, I am proud, and this most certainly is one of them. .And, if I may repeat my self, real mental illness is not to hard to discern.

Thank you Dr. Steve for bringing some of the more thought worthy to the forefront in your field. I begin to doubt my efforts sometimes, but I truly believe in progress and, at least, that can not ever be taken away. I, will never, cave to mediocrity – pretty much never! Best

My dilemma is not so much that I think the society (or the APA, for that matter) wants members “just for the sake of it” or to earn revenue for job fairs, scientific meetings, etc.; instead, if we’re a professional organization that supposedly stands up to defend our profession, what exactly does that mean? Everybody seems to want (or need) something different, so what would we lobby for? Furthermore, for most of the rank-and-file, the consensus seems to be, please let me continue doing what I’ve been doing all along!! whereas I have a very hard time justifying a defense of the current status quo in psychiatry.

What franchise? The ability to provide services sought by the mentally ill. Traditionally, the APA has done a lousy job of franchise-protection. Compare to medicine or surgery.

Do you want to protect the franchise? It sounds like you don’t. For my specialty, I’m fine with people who are not doctors doing virtually all of what I do as a primary care pediatrician. Our professional societies have been better than yours at keeping so-called mid-levels out, but they are losing the battle.

In some settings, our “franchise” is to keep people dependent upon us (and the government) for a degree of financial stability. In other settings, our “franchise” is to mislabel patients and provide excuses for their behavior. In other settings, our “franchise” is to pump patients full of drugs whose effects we do not know and cannot predict. In other settings, our “franchise” is to ignore our patients’ obvious problems (social, economic, substance-related issues) and give a “clean” clinical diagnosis that gives us the warm & fuzzy feeling that we’re “providing services sought by the mentally ill” when in fact we’re shifting their burdens elsewhere. In other settings, our “franchise” is to medicalize the whole spectrum of human behavior and to find niches for new molecules to “correct” it.

I would love to “provide services sought by the mentally ill.” It seems, however, that the only way to do it is to step outside of the “franchise” of organized psychiatry and blaze one’s own trail.

In all due respect, “please let me continue doing what I have been doing all along'”, is very unworthy of those that give a rat’s butt, and it is just not good enough, Just not up to par and try to do that in the real world, Trust me, your years in academia just do not take out the trash on Thursday in (my neighborhood), and they are at least on my Christmas list. I put my money where my mouth is and am quite revolted by the lack of any contingency – do I want everyone in the same bracket of practice in all areas, NO Do I think the socio-ecomics are frightful, YES – never get me started! I, of course, do not expect nor think,, MDs should be in this arena, There are different expecatations from each specialty I have dealt with “distinguished MD speakers”, for the most part “losers”, authors of what???? (trash). It is most difficult in these hard economic times to discern my Thursday garbage collection (of which I am most grateful), and any solidarity for bringing excellence to the field. I have seen it is in danger. If you beat down the private sector, you are in serious trouble. There is much to be said for proof and hard science, and I am an idiot, and at least can figure that out. It ts hard to bring reality to the forefront and guess I will keep beaing my head against the wall, in my case, it could not hurt!

“For my specialty, I’m fine with people who are not doctors doing virtually all of what I do as a primary care pediatrician. Our professional societies have been better than yours at keeping so-called mid-levels out, but they are losing the battle.”

You know…Rob…I really like PAs and NPs. But I feel like their creation has been abused. I like them as a supplement to the doctor in a primary care setting, but I do think that the doctor should be the main person. Otherwise, what is the point of having your own practice? If you’re not heavily involved and there most of the time, then I would think that would defeat the whole point of being a PCP.

I don’t mean you, just some doctors. My last doctor had a PA. But she was only in on Fridays. I saw her a lot and liked her. I exclusively saw her for a while. I thought she was a good supplement to the doctor. My sister sees a doctor with an NP. She mostly sees the NP because she is good with women’s health. And that makes sense to me why a male doctor would have a female NP (to handle girl stuff when the female patient is uncomfortable). But this new doctor I have has 2 PAs that I know of. And people rarely see the doctor. I switched doctor’s after I saw the second PA, and she could not figure out my chart and what the doctor or the other PA had done. That kind of care is WAY too fractured in my mind. You might as well just have an EMR, no PCP, and just go to random doctors who try to figure out each other’s work.

There is another doctor in town who works similar to that. She has two practices and she is only at her practice in my town two times a week. The PA runs the show the rest of the time. And I hear it is really disorganized. The only reason anyone would go there is because of insurance and geography.

Again, I like midlevels, but I think that defeats the whole point of being a primary care physician or someone’s psychiatrist if the midlevel(s) is/are the one(s) running the show. I would think that would actually be a lot of training gone to waste (on the part of the doctor).

I’m gonna add something to my comment about overdependence on midlevels. I was thinking that over-utilizing them is like being a parent who hires a nanny to basically be the parent instead. What’s the point of having kids and being a parent if you’re just going to hire a “midlevel” to do it instead of yourself. Yes, you can technically hire a midlevel nanny to be your replacement, and you can see your kids sparingly and have a distant supervisor role over both nanny and kid. It happens all the time when wealthy, busy parents work all the time and have stuff to do. But why do that? If you need to overdepend on a nanny, you might as well just skip parenthood altogether. Why would you even become a doctor if you just wanted to hire midlevels to work with patients and have a more distant supervisor role? Do we want doctors who don’t have a desire to spend much time with the patients? I would think they would just go into research or be one of those people who examines cadavers.

The issue in the mental health field is that “mid-levels,” and I don’t know exactly what it means, but i’d gander it is psychologists, social workers, counselors, and psychiatric nurses, get similar training and are similarly equipped as psychiatrists for diagnosing mental disorders and treating clients/patients with “psychosocial” interventions. The only things that psychiatrists can do extra is prescribe medications. Because the actual science underpinning psychotropic medications and the ways they are utilized has been shown to be highly suspect, and no matter what their actual efficacy or effectiveness, come with all sorts of risks that the prescribing doctors have not been so great at managing. Basically, psychiatrists derive their seniority from their medical degrees and their prescription power, but the tools and methods of medicine have not really led psychiatry to better care or better patient outcomes.

Because “mid-levels” can do so much of the work as psychiatrists with no difference in effectiveness, because they tend to charge less due to having less “respectable” or less advanced degrees, and because medications are increasingly questioned as worthwhile treatments, psychiatrists don’t have a lot of “franchise” to defend. Not to be too disparaging, but it seems they ride mostly on their respectability as physicians and the meekness of “mid-level” clinicians who undervalue themselves and rely on their adaption to a biomedical mental health framework that lets them get insurance reimbursements.

As a side note, I see way too many social workers who have a better grasp of research methodology and social/economic/political factors that shape people’s experience than psychiatrists, who are supposedly the real experts in science and mental health.

When I refer to ‘franchise protection’, I mean efforts on the part of professional organizations to keep other people from doing what you’re doing.

In psychiatry, there are a slew of shingle-hangers who provide talking therapies, some of whom are credentialed, but many of whom are not. In many states, nurse-practitioners and PA’s can write prescriptions. Not only do I agree that mid-levels do as good a job as MD’s at writing scripts, my personal experience is that they are more careful about doing so.

To explain to Mara, I envision practices that consist entirely of non-MD’s, so nobody has to waste a medical school education or leave their baby with a nanny.

In Pediatrics, there is no reason at all while well-baby and well-child care cannot be handled EXCLUSIVELY by NP’s and PAs. Probably the same goes for most illnesses. Again, in my experience, the majority show excellent judgment in knowing when to seek consultative opinions.

Indeed, it is the opinion of some of the leaders of psychiatry– i.e., those with a much longer-term view of this field than I– that in the future, many fewer psychiatrists will be needed. Those that do continue to exist will be involved in administrative roles, responsible primarily for the initial diagnosis of patients (our “franchise,” I suppose), directing teams of other providers (“midlevels,” although that is not a PC term) to provide the care, and occasionally consulting on difficult cases. This, in particular, is the future as seen by a former UCSF psychiatry chairman who spoke at the conference last weekend.

Hmmm…I read these comments about midlevels and I wonder what this means for doctor’s of all stripes. I actually think that makes sense to have midlevels with their own practices specifically for wellness care. I think this country could use a lot more focus on wellness care and not just sick care. I would think that would even increase access to care if there were lots of NPs and PAs with their own private practices who are responsible just for checkups and handling minor illnesses. Would that actually free up primary care physicians to spend more time with patients with severe illnesses who need more care from a doctor? Could that potentially be a better model? hmm…

Though with psychiatry…I wonder if a lot of psychiatrists would just quit or not have gone to med school if they were relegated to a purely administrative role. I assume people become doctors because they want to work with other people (at least on some level). Otherwise, they would choose a job that didn’t require a lot of interaction with patients. Sort of like a person who really wants to be a surgeon, and then surgeons suddenly stop performing surgery or interviewing patients. They serve as a consultant to a midlevel in charge of interviewing, and then supervise and serve as consultant to another midlevel who is trained to perform surgery. The would-be surgeon might just say, “Well what’s the point of being a surgeon if I’m not ever going to perform surgery? I should have just become a midlevel, because I really wanted to perform surgery and be heavily involved in patient care.” Really. I would think that for some psychiatrists, the idea of being totally administrative would make some of them quit. Because the point of being a doctor is usually to work with live patients who are interviewed and examined. And I assume a potential psychiatrist’s dream is to work with the mentally ill. The same goes for pediatricians. I would think their dream is to work with children. If they work very little with children, that might defeat the point.

Or maybe I have no clue what I’m talking about and all doctors crave administrative roles…but working directly with patients is such a huge part of being a doctor that I would think that would have been a huge factor in their decisions to pay for med school.

I still don’t see why being a physician prepares someone to be an an administrative role. If the future role of psychiatrists is moving in that direction, I would guess residencies would be more focused on training in administrative psychiatry, management, human resources, etc. At this point, many MSWs get more formal management training and often get more group work training. Or why not get someone with a masters in health administration with a clinical license lead teams. Again, I think psychiatrists and to a great extent the public, believe that somehow being a physician qualifies someone for leadership/expertise among non-physician colleagues. Perhaps in non-mental health fields that may seem more appropriate, but there really is an abundance of evidence that mental health care providers regardless of degree produce similar outcomes and there is no reason to believe psychiatrists make better team leaders or administrators. If psychiatrists aren’t better clinicians or managers (so they aren’t inherently able to provide better supervision or manage teams/programs), who would pay them to lead teams?

Again, I think psychiatrists are going to be more and more regulated to prescribing roles and consultant diagnosing (not initial diagnosing) in order to prescribe. Unless psychiatry can better demonstrate the value it purports, I don’t think it will fly in an increasingly managed care environment. If it can’t then I certainly do believe that psychiatrists should not sit on top of the mental health hierarchy, and gasp, might be managed by folks who are now considered “mid-levels.”

Why, may I ask, does the regional organization require membership in the APA?

I suggest requesting an item for discussion on the agenda of the next directors’ meeting about rescinding this requirement. Members may wish to cancel their memberships in the APA in protest of the DSM-5 and the APA’s symbiotic relationship with pharma.

Great question, and, to be honest, it did come up (actually, I was told it comes up every year). A few audience members said they’d be happy to be regional-society members if they could disavow the APA component. It sounds like it will go (again) to the officers of the regional society. My guess, however, is that their hands are tied by the APA, and that this is a rule that only the APA can change.

“The Northern California Psychiatric Society (NCPS) is a district branch of the American Psychiatric Association (APA). ….
The APA has a dual membership requirement whereby APA members must also be members of the district branch within whose jurisdiction they reside or practice.”

There you go, one hand washes the other. The NCPS agenda item might be “can we secede from the APA?”

Honestly, if a N. California organization doesn’t take this up, who will? Maybe one in Oregon.

Good article, Steve. As psychiatry maintains its entrenchment in pseudoscience, which permeates residency programs across the land, I envision newcomers of our specialty being increasingly limited in their capacity to treat our patients. Conceivably, with many in our field, who are comfortable being relegated to a perfunctory and impersonal medication management role, we may see ourselves being outsourced to less expensive psychiatrists internationally via telemedicine. This is already being done in my state, and has been passively supported (through lack of opposition) by our state medical association, despite the objections of the state psychiatric society. Further, the former organization has actively endorsed the medical psychology movement, due to a perceived indigenous shortage of psychiatrists, who have overwhelmingly objected to it. Now, we are hearing clamoring from our ranks to unionize, which will prove to be a futile last resort, if chosen. At our annual meeting 14 years ago, I remember one of our governmental affairs members warning of such encroachment, only to be booed off the podium. That’s when I made the decision to join him in resigning. And now we are there!

I’ve never heard of such a thing (outsourcing psychiatry). But I actually don’t think that is such a bad idea. That could also make it cheaper if the person wants psychotherapy and med management. Telemedicine for psychiatry does not sound like a bad idea.

Telepsychiatry (which currently exists) makes sense in some cases, but in my opinion it’s a poor substitute for the real thing. There’s something to be said for the relationship that develops between patient and clinician when they meet face-to-face. Both diagnostically and therapeutically, that direct connection can be more powerful than any assessment instrument or medication intervention our field currently has to offer. Unfortunately, it’s almost impossible to describe or to quantify, but patients (and clinicians) know it when they experience it.

Even if face-to-face relationship building is often the most therapeutic effect of psychiatric practice, that does not bode well for the field. There are lots of people without such advanced training who demand a lot less money who are excellent at building trusting patient/provider relationships that may alleviate suffering. Pushing that argument I don’t think is great for psychiatry job protection. In bet, carried forward, it would only add to telepsychiatry, non-doctors do most of face-to-face treatment and doctors prescribing medication from afar.

As for organizing for patient care, perhaps alternative organizations outside of the psychiatric societies/associations can form. There is no reason why people can’t be members or active in more than one group.

The excellent points you raise, Nathan, circle back to psychiatry’s need to differentiate itself in the delivery of mental health care.

Currently, there’s no differentiation because ALL the MDs prescribe psychiatric medications badly. If psychiatrists had superior knowledge — which, because the research is so contaminated and they are in such denial, they do not — they could say they prescribe drugs more effectively and safely than other MDs.

If psychiatry could offer superior drug safety, for a while psychiatrists may be helping the general population get off their ridiculous drug cocktails, then they would focus on the small minority who truly need psychiatric care and possibly medication.

If this scenario took place, the world would need fewer (but better) psychiatrists ministering to a small number of seriously ill people.

But the possibility of organized psychiatry in toto seeing the light is not great, and any individual psychiatrist with a conscience is left to contend with defining a practice style that is not shared by most of his or her colleagues and perhaps disdained by some of them.

Thanks for this post, which mirrors my own feelings. I don’t belong to APA, and haven’t joined NCPS (the regional society you mention) because one must also join APA. There are too many APA practices and standards I can’t support. NCPS itself is a pretty good group, from what I know of it. As for the AMA… never mind.

Quite apart from the APA, I envision a unifying philosophy for our field. Maybe I’ll write a very long post, or perhaps a book, about it someday. A coherent view of what psychiatry ideally *is* seems oddly absent in our field, as we fight ourselves and others over the details.

Such a view is not the same as a manifesto that defends psychiatry against interlopers and competitors. I have no interest in those battles. Instead, we should do what it takes to be good psychiatrists — including roles as varied as the panelists you described. If society values what we offer, we’ll survive and thrive. If not, the field will die out. Despite that risk, I’d rather die with my principles on, than to join organizations or espouse positions simply because they’re politically or financially expedient. But that’s just me, on a good day anyway.

Well said. It was initially scary but ultimately liberating and much more rewarding forging out on my own. And the demand is there. Stigmas apply to groups, but reputations are created by the individual. Maintaining my ethics superceded all other concerns when I made that decision, and could only be achieved by establishing my independence. And yes, my income took a hit initially, but has rebounded to a comfortable level. The nice aspect of our profession is that overhead is nominal compared to that of other specialties, so risks are relatively minimal.

I’ve seen this, too. The very few solo psychiatry practitioners who take an ethical approach and minimize drugs seem to be on the top of all the most-recommended lists. Their reputations among patients are stellar.

It may take a while to get known, but patients will really appreciate you, especially after they’ve been to other doctors who have made stupid medication decisions that damaged their lives.

Over half of the psychiatrists in this country are over 55 years old, and retiring.
And it doesn’t look like recruiting efforts are going very well to get young people to join the field.

Which means that psychiatry is dying.
Don’t expect a rallying cry from the public to save the profession. The drug makers have decided to bow-out when it comes to introducing new drugs (clinical research), and a growing number of us would prefer taxpayer money be spent on holistic treatment that works, rather than failed drugs and “treatment” that only caused more harm than good.

I’ve read a number of your postings through the years and while there is some validity to what you offer up there is a population of seriously ill individuals with whom I am most familiar having no situational issues such as bad parenting, sibling rivalry, maturational distress, bullying, trauma etc., etc. as the causation for their serious depression and subsequent suicidal ideations.

This same population has often gone decades seeking relief which often encompasses years of talk-therapies and holistic approaches, that you appear to rave about constantly, as well as nutrition and the use of medications without efficacy.

Therefore I strongly feel your thoughts of “psychiatry is dying” are extremely short-sighted and narrow as are your generalities and thoughts relating to treatment options. Each individual is unique and in my opinion so too should the administration and modulation of therapies after a very careful diagnostic process and evaluation. Each treatment has its place and time and to narrow one’s thoughts to one or two therapies or to denigrate any therapy benefiting an individual is again very short-sighted in my opinion and a great disservice to the patient.

As a devoted husband, support person and health care advocate for my spouse approaching 5 decades I can state we’ve been fortunate to have many trusting, caring and knowledgeable psychiatrists as well as psychologist who have collaborated with us through the years to finally achieve control, stability and remission of my spouse’s illness. It would have been wonderful early on had we succeeded with “holistic treatment” or any of the numerous talk-therapies undertaken through the years. The fact is, in my spouse’s case history, it was a waste of time, effort and monies. Issues of the nature you tend to always speak of were absent.

I strongly advocate for patient education while endorsing hope and persistence. I encourage the use of the least invasive therapy options as an initial starting point for one’s treatment but I do not limit choices nor do I endorse any therapy, products and/or companies. I’ll also point out that when a physician hangs out their shingle to practice it does not state if he/she was first or last in their class. Additionally, there are doctors, good doctors and better doctors. And as part of the educational process it is incumbent upon the patient and/or one’s support persons to seek out those better and caring doctors.

[…] and these other specialties, as I truly believe we can coexist and complement each other. But as I wrote in my last post, psychiatry really needs to stand up for something, and this would have been a perfect opportunity […]

I can tell you from personal experience that psychiatrists aren’t the only group of medical doctors who look at drugs as the first option for various conditions when other treatments should be tried first. As a result, it is a mistake to demonize psychiatry when this problem seems to be so common in medicine in general.

Anyway, the chances of psychiatry dying are as great as my becoming a millionaire.

Having worked with people with epilepsy, I know it can be of benefit for uncontrolled seizure disorders, but it seems awfully invansive for “mental illness” (depression).

Psychiatry has made the claim that “bipolar disorder” is similar to seizure disorders, which is how it expanded the use of anti-convulsants, during its “decade of the brain.”

I’m not a doctor, but having counseled, and worked closely with people who have epilepsy, I can tell you up-front, in common sense, and layman terms – seizure disorders are not “mood swings” or “depression.”

That’s the problem with psychiatry… it continues to want to share a place with neurology and other forms of legitimate medicine, and it never will… because it is not based on real science, nor real “medicine”.

VNS seems awfully invasive for “depresson”, IMO.
I know one woman with severe depression who tried it, and it was a faiure, as were her countless ECT “treatments” (brain concussions).

“….The overall downward trend has occurred for the past six years, according to a National Resident Matching Program report….

….there could be several factors, said Dr. James Scully Jr., the APA’s medical director and CEO.

“This is a very exciting time for psychiatry, when we have more scientific developments in the field than ever before, but this means that the field is evolving in ways in which the outcome is unknown,” Scully said in the news release. “It’s a great time for young doctors to have an impact on what the future of psychiatry will look like.””

I tried to write this several times, it all comes down to psychiatrists must be scientists and not doctors. This is maybe why Dr. Pies advocates that only psychiatrists prescribe.

Patients also need to be scientists of their own diseases, Dr. Jim Phelps wrote an article about that recently.

Patients and doctors are also not much helped by the “Bright Sided”(Barbara Ehrenreich) society in which they are expected to function. I was nurtured in a society in which suffering, while not welome, was an expected part of life. Maybe the best way to feel a little better is to feel that it is ok to feel bad. Maybe that’s what the placebo effect is.

Thanks for your response. As I’ve mentioned previously I’ve read your comments for some time both here and upon a number of other forums and quite frankly your position in my opinion has consistently been biased and quite frankly from the vantage point of a support person detrimental for my purposes.

Yes, we both are in agreement that individuals have the capacity to recover from these illnesses but unlike your position and statements I strongly advocate for as many treatment options as possible. I do so knowing the uniqueness of these individuals and so too the variation in responses, failures and potential for side-effects and all the more reason the need for as many treatment choices as possible.

An example of your biased writings, in my opinion, is your statement:

“I’m curious about the Vegua Nerve Stimulator (VNS).Having worked with people with epilepsy, I know it can be of benefit for uncontrolled seizure disorders, but it seems awfully invansive for “mental illness” (depression).”

Why would Vagus Nerve Stimulation be awfully invasive for depression and not so for Epilepsy? It is a surgically invasive procedure for both maladies and to which I’ll also add it is also a benefit to a number of depression and bipolar patients who otherwise have been unable for decades to achieve any degree of efficacy. Importantly and maybe absent of your knowledge is the fact that those who do benefit for depression are also doing so long-term.

Neither is I a medical professional but I am a long-time observer and empirical data recorder and I am knowledgeable enough to know that a number of forms of epilepsy exhibit abnormal neuro-biochemical discharges within the brain and concurrent with that illness one often encounters serious depression and/or mood disturbances. It was the reporting of epilepsy patients utilizing VNS Therapy that initiated the studies for its use in depression. The epilepsy patients while benefiting from the therapy for their seizure disorders were also reporting the diminishing of their depression.

I’m not qualified to address psychiatry sharing any place with neurology. I’ll leave that to you and others but on the other hand I am pragmatic and I have the additional chosen responsibility of caring for a loved-one. Neurology lacked answers for my purposes. There have been no neurological medical tests to date to account for my observations of my spouse’s mood states and serious illness (major depression with suicidal ideations). Unlike your positions and statements regarding a particular branch of medicine and/or treatment options I chose not to degrade and/or denigrate Neurology for their lack of answers and failures to help us. Instead, we simply moved on and sort help elsewhere. As a former DBSA facilitator, President and Board Member of local chapter I can also relate to hundreds of similar narratives. I am knowledgeable both from personal relations, readings and collaborations that what may have been beneficial to others did not work for my spouse and vice-versa.

The point being neither you nor any medical professional can guarantee the long-term efficacy of any treatment option offered to this unique patient population of which my spouse was one of them.

Again, to illustrate what I consider biased writings is your additional statement:

“…because it is not based on real science, nor real “medicine”.VNS seems awfully invasive for “depresson”, IMO.I know one woman with severe depression who tried it, and it was a faiure, as were her countless ECT “treatments” (brain concussions).”

The Art of Medicine is an evolution utilizing applied science and contrary to your opinion(s) as it relates to Psychiatry, as I mentioned elsewhere, I believe it is evolving and only in its infancy. Yes, like you I too am aware of individuals not benefiting from VNS Therapy. But even more importantly, I collaborate with individuals who for the first time in decades have their lives returned to them as a result of utilizing the very same therapy. I too am aware of individuals unsuccessfully utilizing ECT. Then again there are many who have benefitted that you simply might not be aware of. What most troubles me is your remark “brain concussions”. Have you reviewed the MRI’s or CT SCANS of the woman you cited? My spouse has had a number of ECT in the past. She’s also had numerous MRI’s and CT scans and blood workups. It is strange but in all the neurological readings of these tests throughout the years no neurologist has diagnosed or suggested “brain concussions” and/or abnormalities. Now why is that?

On the other hand, ECT in the past quickly aborted my spouse’s suicidal ideations. Cognition and retrograde memory challenges were short lived. In fact, my spouse recalls telephone numbers from 50 years ago. I can’t even recall our daughter’s telephone number. Again, why is that?

The point being as I’ve participated and read through various forums such as this one with individuals like yourself advocating for the banning of this or that treatment, medication and/or medical practice etc., etc. there would be no option choices for my spouse to choose from to have helped her recovery. I personally find that unacceptable.

Of what possible utility is diagnosing subjective symptoms and treating them as their own disease, solely with treatments that don’t address the cause?

A good example is depression.

Psychiatry considers the subjective symptom of depression to be it’s own disease process, and treats the symptom with drugs, such as antidepressants. The drugs do not address the cause of illness, and basically just disrupt normal brain function to get a subjective effect.

A doctor outside of psychiatry would consider Depression to be solely a symptom of a medical condition, such as a B-12 Deficiency, hyper or hypothyroidism, drug dependence, etc. A doctor would perform a blood test for these conditions, and if anything showed up it could be treated accordingly, curing the problem if possible.

The same problem exists with psychotherapy, it does not address the cause of illness. In truth, psychiatry treats the ‘mind’, while for example, Neurology treats the nervous system (brain). Psychiatry literally believes that ‘mental illness’ is a subjective thing that exists in what is essentially a philosophical place. Psychiatry does not believe the brain is a machine, or that it malfunctions to produce ‘mental illness’.

Rather, if the cause of a particular ‘mental disorder’ turns out to be physical, like Alzheimers, Parkinsons, Huntingtons, and epilepsy, then the illness becomes a neurological condition and leaves psychiatry.

While I understand some people need therapy to get though traumatic events such as abuse, there is literally no utility for a medical specialty that does not treat, nor accept, the actual cause of illness. The only possible result is that Psychiatry will be medicating B12 deficiencys and other medical problems with antidepressants, causing the only possible outcome: a worse one.

Because psychiatry is more philosophical then physical, it’s been pretty easy for pharmaceutical companies to hijack the profession and mislead it with pseudoscience. Perhaps nowhere is this more self-evident then the funding crisis within psychopathology.

“There are potential suicide victims who prefer to turn to rec-reational drugs and alcohol because the prescription drugs the medical profession has to offer are ineffective or make them feel even worse (Hendrie and Sarailly, 1998). Psychiatric patients are left to roam the streets and soldiers are returning from war with posttraumatic stress disorder that we have no way to treat.”

“We do not have the luxury of allowing preclinical psycho-pharmacology to disintegrate when we already know that no amount of tinkering with existing drugs will ever make them adequate because the theories on which they were based are wrongheaded”

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Steve Balt

All posts, unless otherwise noted, are written by Steve Balt, MD, current Editor-in-Chief of The Carlat Psychiatry Report (TCPR). TCPR is a monthly continuing education newsletter for psychiatrists and other mental health professionals with a focus on practical tips, clinical pearls, and reviews of research with the promise of no pharmaceutical or device industry bias. Read more about Dr. Balt on his About Me page.